Study Evaluates Sexual Health After Caesarean Vs Vaginal Delivery Interview with:
Florence Z. Martin
MRC Integrative Epidemiology Unit
Population Health Sciences
Bristol Medical School
University of Bristol, Bristol, UK What is the background for this study?

Response: Globally, rates of caesarean section are on the rise. Many things are contributing to this, including increasing maternal age, more women who have had prior caesareans, and changes in maternal preference. One reason that women have been cited to choose a caesarean in an uncomplicated pregnancy is the maintenance of sexual wellbeing postpartum (in other words, after their baby is born). The protection of sexual wellbeing following caesarean section is thought to be via the maintenance of vaginal tone and reduced risk of vaginal tearing.

However, few studies have shown this to be true. Some studies investigating sexual outcomes in the year after birth found no difference between women who gave birth vaginally and those who delivered via caesarean section. Longer term evidence is sparse, with only one study looking up to 16 years postpartum and finding that women who give birth to all their children via caesarean section are at higher risk of experiencing sex-related pain.

To contribute to previous studies and provide the first piece of evidence looking at sexual wellbeing as a whole several years after delivery, we used data from the Children of the 90s study (also known as the Avon Longitudinal Study of Parents and Children or ALSPAC). We aimed to compare sexual enjoyment, sexual frequency, and sex-related pain between women who delivered via caesarean section and those who delivered vaginally up to 18 years postpartum. What are the main findings?

Response:  There was no difference between women who gave birth via caesarean section compared to those who gave birth vaginally for either sexual enjoyment or sexual frequency. The finding was the same from 33 months postpartum through to 18 years after delivery. We also found no difference in these outcomes when comparing instrumental vaginal delivery (where forceps or a vacuum were used to deliver the baby) with non-instrumental vaginal delivery.

However, we found that women who had a caesarean section were more likely to experience sex-related pain at 11 years postpartum, specifically in the vagina during sex, than women who gave birth vaginally. Both emergency and elective caesarean section were associated with an increased risk of sex-related pain at 11 years postpartum. What should readers take away from your report?

Response: Our findings are in line with the limited research already published in this field. We found no difference between delivery groups for sexual enjoyment or frequency at any time postpartum, however we did find that women who gave birth via caesarean section were more likely to report sex-related pain at 11 years postpartum.

In relation to the pain findings, it is important to consider what might be going on. It is plausible that having a caesarean section causes sex-related pain, however there is another, potentially more plausible, explanation. Given that we didn’t have pre-delivery measures of sex-related pain, we were unable to ascertain whether women who had a caesarean section had higher rates of sex-related pain prior to their delivery. In other words, women who experience more sex-related pain pre-delivery may be more likely to have a caesarean section and more likely to have sex-related pain post-delivery.

It is also important to consider the other limitations of our study. To define mode of delivery, we used the index pregnancy from Bristol’s Children of the 90s study, which means the delivery of the child enrolled in the study. That meant that we weren’t able to take into consideration any deliveries that had happened before or after the index child. We dealt with this problem as much as we could with extra analyses, but it was still a limitation of the study.

Overall, we used a wide range of statistical methods to overcome as many of the problems with the data as we could and provided a piece of high-quality evidence to inform the debate surrounding the impact of delivery method on sexual wellbeing. Although the findings will not affect decision-making in the delivery suite, they may help open dialogue between a woman and her clinician postpartum if she is experiencing sex-related pain. For women planning a caesarean section in an uncomplicated pregnancy, the evidence provided here may help further inform that decision. What recommendations do you have for future research as a results of this study?

Response: As discussed above, it is important for future studies to consider pre-delivery sex-related pain in these comparisons to understand whether sex-related pain predicts caesarean section, as opposed to the other way round. The study has also highlighted the need for more studies to address all issues related to caesarean section and long-term maternal wellbeing outcomes to guide decision-making and improve care for women postpartum. Is there anything else you would like to add? Any disclosures?

Response: We are extremely grateful to all the families who took part in the study, the midwives for their help in recruiting them, and the whole team from Children of the 90s, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists, and nurses.


Martin, FZ, Madley-Dowd, P, Ahlqvist, VH, Jónsson-Bachmann, E, Fraser, A & Forbes, H Mode of delivery and maternal sexual wellbeing: A longitudinal study. BJOG. 2022; 00: 1– 9.

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Last Updated on August 25, 2022 by Marie Benz MD FAAD